Inspection on 11/06/07 for St Ann`s

This inspection was carried out on 11th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Ann`s 27/06/06

St Ann`s 01/09/05

St Ann`s 02/05/05

St Ann`s 13/12/04

St Ann`s 13/04/04

St Ann`s 13/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Ann`s The Crescent Kettering Northants NN15 7HW Lead Inspector Keith Charlton Key Unannounced Inspection 11th June 2007 02:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Ann`s Address The Crescent Kettering Northants NN15 7HW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01536 415637 01536 519304 stanns@bmcarehomes.co.uk Collycare Limited T/A B&M Care Mrs Teresa Ann Hayward Care Home 39 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (39), of places Physical disability over 65 years of age (4) St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to 7 service users with dementia may be accommodated on the First Floor A maximum of 14 service users with dementia may be accommodated on the ground floor A maximum of 4 service users with a Physical Disability can be accommodated on the first floor. 27th June 2006 Date of last inspection Brief Description of the Service: St Anns is a care home providing personal care and accommodation for 39 older people over the age of 65 years. Collycare Ltd trading as B & M Care owns the home. The home is located in Kettering Town and within walking distance of the train station and town centre shops and amenities. The home is purpose built and separated into two self-contained units on two floors. A passenger lift provides access to the first floor. On the ground floor, the home can care for 14 Older People who have dementia. On the first floor the home can care for Older People including up to 7, who have a mild form of dementia and up to 4 with a physical disability. 27 of the bedrooms are single occupancy and 20 have en suite toilet facilities. The home has an enclosed garden, which is well maintained, and has a small raised fishpond accessed directly from the ground floor lounge. The following fees were provided by the registered manager as being current at the time of this inspection, between £338 and £450 per week. The fees include personal care, accommodation, meals and laundry. Chiropody and hairdressing services can be arranged and are charged separately. The Registered Manager stated that residents are provided with a service users guide to the services the home offers, when requested by them or their relatives. The home’s Statement of Purpose is displayed in the reception with a copy of the last Inspection Report so that this information is accessible to residents and visitors. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on duty. Planning for the Inspection included checking on the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report. There has been one complaint made to the Commission for Social Care Inspection since the last inspection, which was passed onto the Registered Provider to investigate. There was no evidence to support the allegations made. The Inspection took place between 14.30 and 16.40 and included a selected tour of the home, inspection of records and indirect observation of care practices. The Inspector spoke with six residents, three staff members, and five relatives. The Inspection was concluded at the end of the week with the Registered Manager. What the service does well: Residents said that staff were friendly and helpful towards them, and reported that staff welcome visitors. Staff were observed to be friendly towards residents and assisted them at the residents pace. A staff member was observed to spend time with a resident who was agitated by speaking softly to her and holding her hand, reassuring her and bending her body so that she was at the same level as the resident. This had the desired effect of calming the situation. The Registered Manager stressed the importance of touch to residents and holding their hands thereby showing consideration is given to residents emotional needs as well as their physical care needs. Residents said they would have the confidence to raise concerns if they needed to and were satisfied that the concerns would be listened to and acted on by staff and management. A record of daily living choices is part of residents St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 6 Care Plans so that individual wishes are known and followed. Residents spoke positively about the activities arranged and extensive records are kept as to details of activities that are provided. Routines in the home are relaxed and residents were able to get up and go to bed as and when they were ready. The standard of cleanliness was generally very good and re-decoration in the future is planned. There was evidence that residents’ and relatives are encouraged to give their views on the care provided. Results of a recent survey, which were mainly very positive, were displayed in the home with details of the actions that were going to be taken to address any less positive issues raised. Staff thought they were generally valued in their performance of their jobs and staff training is encouraged by the Registered Manager in order to equip staff to meet residents needs. What has improved since the last inspection? What they could do better: The overall care residents receive appears to be good however the lack of detailed care plans to guide staff in the actions they need to take to meet residents’ needs means residents needs may not be entirely met. There is still a problem with controlling the temperature in areas of the home was making life uncomfortable for residents and staff. The inspection took place on a hot day and the radiator in one bedroom was found to be hot and could not be adjusted. There were many comments received by the inspector that the building was too warm. This could have a detrimental effect upon residents and staff in terms of people being sluggish, short tempered and at risk of dehydration. The registered manager has discussed the problem again with head office to seek a resolution but this has not been acted upon. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 7 The Registered Manager was recommended to look into providing more signing and colour coding systems for facilities to make them clearer for residents with dementia and of providing other aids to reminiscence, e.g. memory boxes. Fire precautions must always be followed regarding Requirements from the Fire Officer and fire doors not being wedged open Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process is well managed but information gathered needs to be expanded to meets all residents needs. EVIDENCE: Residents said that they could visit the home prior to their admission if they were physically able to do so, usually by way of a trial period, to give them a good idea of what services the home offers. There was evidence of assessments undertaken by the Registered Manager available on the residents files examined by the inspector, which covered some of their needs, allergies, medical conditions etc but this was of a basic nature. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 10 The Registered Manager agreed that she would refer to the National Minimum Standard and include all relevant information in it. The home does not provide intermediate care facilities. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans describe identified care needs to ensure care is supplied by staff, though these need to be more detailed to meet all needs. Health and medication systems generally protect the safety and welfare of residents. EVIDENCE: No residents could recall having a Care Plan or being involved in setting it up and reviewing it. However there was evidence on file that relatives had signed Care Plan reviews. The Registered Manager said she would remind residents and relatives that there were plans that residents could see and comment on them if they wished. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 12 Residents needs are detailed in their Care Plans and all residents case tracked had a plan of care in place. The registered manager stated that care plans have not been reviewed monthly but this would commence and be recorded in the Plans. Residents personal histories are part of the plan so that they can be seen as individuals with a valued history, though two seen were blank. The Registered Manager said this issue would be put in place. Residents with continence problems did not have evidence of a referral to medical services or specific information in place to indicate to staff when they needed to go to be assisted to go to the toilet. The Registered Manager said this issue would be put in place. One resident thought that help was not forthcoming from staff helping her to dress. The Registered Manager said she would review this, as the home’s policy is to encourage residents independence but not refuse help if requested by residents. Risk assessments also form part of Plans to reduce the risk of harm from identified risks, e.g. there were falls risk assessments in place. The inspector viewed accident records. There was a discussion between the Registered Manager and the inspector as to when the GP should be called if there had been a potentially serious injury, e.g. a head injury. The home has a procedure in place for frequent checks to be made following a fall though to make this a more fail safe system the Registered Manager said referral to medical services would be put in place. Residents all said that staff were very friendly and that they respected their privacy, e.g. they always knocked on doors before entering. The inspector also observed that staff were friendly and respectful to residents and that one staff interacted very well with a resident who was agitated by holding her hand and speaking to her in a calm and friendly manner. Some comments were received that a small number of staff spoke sharply to residents and told residents with dementia to sit down in a curt manner rather than trying to work out what they needed or to allow them to walk around the home if they were safe to do so. The Registered Manager said she was aware of such concerns and the staff in question would be monitored to ensure their practice promoted the respect and dignity of residents. The medication system was inspected. The Registered Manager and staff confirmed that only senior staff issue medication. Senior staff confirmed that they had received training in medication practice. Medication recording was not fully complete as there were some gaps observed on the record of medication issued to residents. The Registered Manager said that she would speak to the pharmacist regarding ensuring the GPs St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 13 instructions for some medication to be on an as needed basis was changed on medication sheets. Controlled drugs records inspected were satisfactory. The medication round was observed by the inspector and found to be efficiently carried out. Medication is securely kept in locked spaces. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to lead full lifestyle and can exercise choice. The food is generally seen as good. EVIDENCE: Residents and relatives said that there were a range of activities at a good level and frequency, and that there was a choice as to whether they wanted to attend them. An Activities Organiser is employed five afternoons a week to provide stimulation. There was one comment received that there should be activities seven days a week. The Registered Manager said this was already the case as staff had time to spend with residents on the other two days, but she would look into the provision of activities on the two other days. The Registered Manager said that the new Activities Organiser had asked residents on an individual basis as to the activities they wished to have. This situation is seen as good practice. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 15 The inspector observed a singsong taking place, which residents appeared to enjoy. There were some comments that some residents would like having more outings and not just one a year, as at present. The Registered Manager said this had been difficult to arrange before but would consult residents and relatives and set this up as necessary. The Registered Manager was asked to consider the provision of ‘memory boxes’, containing valued items, to be set up for residents, particularly for residents with dementia, so as to provide valuable reminiscence material for staff to talk to residents about on a one to one basis. It was recommended that the Activities Organiser attend training regarding the provision of activities for residents with dementia. Residents said that there were no rules that they knew of, e.g. no one reported that there were set going to bed and rising times, and all thought the atmosphere of the home was friendly and relaxed. One resident thought she would not receive breakfast if she got up late. The Registered Manager said this was not the case and she would inform residents through a residents meeting of this. It was recommended that the frequency of residents/relatives meetings be increased to give a greater say in the running of the home. Residents said that their religious needs are respected. The inspector noted on medication records that residents are able to self medicate if they are able to do so, which promotes their independence. Some residents were unsure that they were able to bring in their personal possessions, including furniture. The Registered Manager said she would remind people they could do so - the policy is already in the Statement of Purpose. Both residents and relatives stated that visitors are always welcomed to the home and no one reported any restrictions. The visitors spoken to thought that staff were very friendly and welcoming. The inspector observed that there were many visitors to the home, which helped to create a relaxed and friendly atmosphere. There were generally very positive views regarding the food. A resident said she was able to choose whether she wished to eat her meals in the dining room or in her room. There was a comment that fresh fruit was not generally available. The inspector checked this and fruit was in found in a store. Staff said that often slices of fruit were offered to residents in the afternoon and it was always available on request. Some foods appeared to be of a basic nature – a number of sausage dishes, chicken burger, fish cakes etc. The Registered Manager said this would be reviewed and residents asked what they would like. The inspector also noted St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 16 that generally only one vegetable was served at the main meal. The Registered Manager said this issue would be followed up. The inspector tasted the food at dinner – this consisted of two choices of main meal and dessert, and was found to be well cooked/prepared and had flavour. Records did not always show two set choices each day. The Registered Manager said she would remind the cooks to always record this as choices were always on offer to residents. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident in the system of managing complaints though staff all need have a good level of understanding regarding how to refer to outside agencies if abuse is suspected. EVIDENCE: Residents and relatives said that they thought that if there was a problem then they had confidence that the Managers or other staff would sort it out. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to a relevant Agency, e.g. the local Social Service Department, as per the National Minimum Standard. The Registered Manager said this procedure would be altered to reflect this standard. Staff members spoken with were generally the in house arrangement of who to report the agencies to contact if the in house Manager said this issue would be followed St Ann`s aware of the procedure regarding to but were not aware of most of procedure failed. The Registered up by referring staff to the short Version 5.2 Page 18 DS0000012921.V338445.R01.S.doc procedural statement displayed in the staff room, which has contact details of all statutory agencies that staff need to be aware of. The homes records were inspected. There was one complaint, which had been dealt with professionally. There was also one complaint recorded in the displayed ‘niggles’ book. The inspector advised that this book did not preserve confidentiality, and that the ‘niggle’ needed to be treated as a complaint with the action taken to solve the issues clearly set out and provided to the complainant. The Commission for Social Care Inspection has received one complaint about the service since the last inspection, which was not found to have any evidence to support the allegations made. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Facilities are generally seen as homely and clean by residents and their relatives though the heating problem still needs to be rectified. Odour control is of a good standard. EVIDENCE: The residents spoken to were all content with their bedrooms and happy they could bring in their own personal possessions though were uncertain they could accommodate their own furniture. The Registered Manager said she would remind residents that this is their right, subject to fire Regulations. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 20 The inspector spent time in the communal lounges and dining rooms and met with a number of residents and relatives in lounges and bedrooms. All areas of the home seen were decorated, furnished and maintained to a generally good standard. Furnishings are comfortable and of a good quality. Communal areas consist of three lounges, two dining areas with access to the garden on the ground floor. It was again noticeable, as per the comment in the last Inspection Report, that the home was very warm with some radiators on when the warm day did not require any more heat, and a great many comments were received complaining of this heat that was said to be the case all year round. The inspector noticed that a radiator in a residents bedroom was on when there was no need for more heat and there were no controls to turn it off. The Registered Manager acknowledged this problem and said she was still awaiting Head Office to take action to resolve the problem. There was evidence that the Registered Manager had informed Head Office though there had been no action to date. One Requirement from the Environmental Health Officers Report of July 2006 had still not been complied with regarding the need to repair kitchen units. There was a health and safety issue regarding an uneven path in the garden that needed action to prevent people falling. The home was found to be very clean with no unpleasant odours though communal carpets to the staircase and first floor corridor were heavily stained. The Registered Manager said they are to be replaced soon. There were some comments that the home laundry was not as good at weekends as there is no laundry cover then, and a number of comments that laundry had gone missing or clothes had shrunk as they were not put on the right wash. The Registered Manager said she would organise this cover to ensure that standards are being maintained. There is a maintenance book but checks are not carried out on a regular basis. Other issues that need attention include the redecoration of the first floor dining room, some bedrooms need repainting, replacement of some windows, a proper ramp to the front door as there is a step there that makes it difficult for wheelchair users to negotiate, en suite flooring is stained and needs replacement, and tiles in the front hallway are loose and cracked and need replacement. Again there was evidence that the Registered Manager had informed Head Office of these issues but there had been no action to ensure they were in place. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet residents needs. Recruitment processes are thorough to ensure the full protection of residents from unsuitable staff. A staff training programme is in place to meet the needs of residents. EVIDENCE: Positive comments were made regarding staffing numbers and the ability of staff to respond to residents needs. The rota and the Registered Manager confirmed that there were always a minimum of six care staff on duty during the morning and five in the afternoon, and at night there are three awake staff. The Registered Manager said that there is currently no need for extra staff to be on duty before 8am as most residents were not up then. Residents were very happy with the staff team and said they are very helpful, with residents and relatives saying that they worked very well as a team. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 22 Three staff files were inspected and all contained Protection of Vulnerable Adults checks prior to staff commencing employment, with other information, references etc. in place. This protects residents from unsuitable staff. Staff files contained evidence of training on essential care practices – food hygiene, fire, challenging behaviour, health and safety, first aid, infection control, dementia, etc. It is recommended that there is a Training Matrix to clearly identify what staff needed which training. The managers and staff stated that staff are encouraged to undertake National Vocational Qualification training. The Registered Manager said that the home was meeting the National Minimum Standard of 50 of staff with National Vocational Qualification level 2 or 3 training, as currently only two staff had attained not this, and the Registered Manager and the two Deputy managers had passed their National Vocational Qualification level 4 training. This situation is commended. Discussion with the Registered Manager indicated that the induction programme used for new staff is probably based on the National Training Organisation (Skills for Care) Standards, as per the National Minimum Standard, though this would be checked and action taken if necessary. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to protect the health and safety of residents, though need to be strengthened to preserve fire safety. EVIDENCE: Residents, relatives and staff said that they thought the managers were very organised as to the running of the home. The Registered Manager has a National Vocational Qualification level 4 in Care Management and the Registered Managers Award. There was evidence on staff records that staff have one to one supervision and staff confirmed this occurred on a regular basis. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 24 Staff Meetings have been held though infrequently. It was recommended to the Registered Manager that regular meetings are held to provide a forum for discussion as to all relevant issue regarding the running of the home and staff asked if they would like to add items to the agenda. The Registered Manager said residents meetings are held, though minutes of the meetings were not available at the time of inspection. It was recommended to the managers that meetings be held more frequently so that residents and relatives have more opportunity to express their views. There is a Health and Safety folder with Risk Assessments for safe working practices. This needs to be extended, as there are some radiators without covers to protect residents from burning. A Quality Assurance system was in place. This had been supplied to residents and their families, and other stakeholders, e.g. GPs, District Nurses etc and a summary of findings had been displayed in the home. It was recommended that the summary of findings is included in the Statement of Purpose. There are monies records, which were checked and largely found to be in order though needed two staff signatures to witness each transaction. Fire Precautions: The inspector noted that a number of fire doors were on approved closures so that they could be held open, as they can shut and preserve fire safety when fire bells sounded. However fire doors to the lounge/dining room were wedged open by chairs and therefore would not close when needed. The Registered Manager thought that residents did this and staff would be asked to closely monitor this in the future. The inspector saw the last Fire Officer’s Report. Not all Requirements made had been carried out. The Registered Manager said she had brought this to the attention of management and expected action on this in the short term. Fire training is regularly carried out. System testing was on required schedules for fire bell testing though there had been some gaps of over a month for monthly emergency lighting testing though also evidence this had been rectified recently. There was a fire risk assessment on file. Staff members were asked about the fire procedure and were aware of the procedure. The hot water temperature was checked in a bathroom and found to be 44.8c; this nearly met the National Minimum Standard of 43c. There was evidence of regular hot water temperature testing. The Registered Manager said this would be checked again to meet the National Minimum Standard. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X 1 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement Facilities need to be kept in a good state of repair and décor and be regularly maintained. Ventilation and heating systems should be improved to ensure they can be adjusted to meet residents needs. The Health and Safety systems in the home must protect the welfare of residents from harm with regard to the protection from fire. The Requirements of the Fire Officer must be always swiftly attended to. Timescale for action 11/09/07 2. OP25 23 11/07/07 3. OP38 13 11/07/07 St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP7 Good Practice Recommendations A full assessment of residents needs must be in place before admission. Up to date care plans must be in place, which cover all areas of care needs including incontinence and other health care needs, which detail the required actions of care staff. St Ann`s DS0000012921.V338445.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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